Provider Demographics
NPI:1174860001
Name:ROBERT J. GRAHAM O.D. INC
Entity Type:Organization
Organization Name:ROBERT J. GRAHAM O.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:805-646-8510
Mailing Address - Street 1:PO BOX 880
Mailing Address - Street 2:
Mailing Address - City:OJAI
Mailing Address - State:CA
Mailing Address - Zip Code:93024-0880
Mailing Address - Country:US
Mailing Address - Phone:805-646-8510
Mailing Address - Fax:805-646-2968
Practice Address - Street 1:635 E OJAI AVE
Practice Address - Street 2:
Practice Address - City:OJAI
Practice Address - State:CA
Practice Address - Zip Code:93023-2822
Practice Address - Country:US
Practice Address - Phone:805-646-8510
Practice Address - Fax:805-646-2968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP8729152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD00872901Medicaid
4459640001Medicare NSC
OP8729Medicare PIN
CASD00872901Medicaid